Approach Considerations

Given that patients with possible appendicitis may have an equivocal history and physical examination findings and inconclusive supporting test results, the following measures are key to any evaluation and treatment plan:

Relieve the patient's pain and discomfort early and consistently

Communicate with the patient and family about the plans

Repeat the examination often

Adjust the differential diagnosis as appropriate

Keep the patient for observation if a firm diagnosis is not made or for follow-up

Algorithms, scoring systems, imaging studies, and consultation reports are part of the clinician's armamentarium. Documentation of medical decision making is important, as is knowledge of the current literature. Consultations with a pediatrician or general surgeon may be appropriate.

Because of the short time from obstruction of the appendix to perforation, 20-35% of patients who present with acute appendicitis have already perforated. In fact, estimates suggest that most patients perforate within 72 hours of symptom onset. A substantial risk of perforation within 24 hours of onset was noted (7.7%) in one study and was found to increase with duration of symptoms. While perforation was directly related to the duration of symptoms before surgery, the risk was associated more with prehospital delay than with in-hospital delay.
[1]

If a patient presents beyond 72 hours from symptom onset, perforation is highly likely. However, if a patient presents with symptoms of appendicitis beyond 72 hours and has not perforated, diagnoses other than appendicitis must be entertained.

Avoid treating vague abdominal pain by administering parenteral opiates and then discharging the patient. Narcotics and potent nonsteroidal anti-inflammatory drugs may be needed for pain control. Large doses or ongoing use should be avoided until after surgical consultation.

Patients with a classic history require prompt surgical consultation. Maintain nothing-by-mouth status in patients with suspected appendicitis, and start intravenous fluids to restore intravascular volume. Antibiotics should be started upon diagnosis of appendicitis.

Emergency medical service (EMS) personnel are well trained and cognizant of how to assess and begin treatment of the febrile, vomiting child with abdominal pain. Intravenous fluid administration, pain management, and antiemetic medication should be administered based on local EMS protocols.

The insertion of nasogastric tubes (when necessary), intravenous lines, and urethral catheters (when necessary) and the administration of antibiotics, antiemetic drugs, antipyretic drugs, and analgesia should ideally be part of the emergency department protocol for preoperative management.

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Fluid Resuscitation

Ensure adequate hydration for patients who present with suspected appendicitis. Even in early acute appendicitis, children frequently have not had sufficient oral intake and present with some degree of intravascular dehydration. Intravenous hydration often improves abdominal symptoms in children who do not have appendicitis.

Patients with appendicitis usually require fluid boluses prior to operation in order to counteract dehydration. However, these patients need continued fluid resuscitation appropriate to their fluid status and severity of appendicitis.

If fluid status is unclear, urine output is the most common measure. Urine output should be no lower than 0.5 mL/kg/h. If dehydration is suspected, Foley catheter placement, monitoring of urine output, and correct fluid replacement are indicated.

Postoperatively, the spectrum of fluid management ranges from patients with early appendicitis who are started on clear fluids postoperatively and can have intravenous (IV) fluids discontinued when advanced to a regular diet, to patients with perforated appendicitis who require postoperative fluid boluses.

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Antibiotic Therapy

Antibiotic therapy is an important aspect of the treatment of ruptured appendicitis. Intravenous antibiotics should be started once the diagnosis of acute appendicitis is confirmed. Antibiotic therapy should be directed against gram-negative and anaerobic organisms such as Escherichia coli and Bacteroides species.

If the appendix is not gangrenous or perforated, no postoperative antibiotics are indicated. A gangrenous appendix warrants antibiotics for 24-72 hours, depending on clinical improvement and/or Gram stain, if one was obtained during surgery.

Antibiotic therapy for ruptured appendicitis is continued for a minimum of 7-10 days, but a longer course may be needed. Intravenous antibiotics are used during the hospitalization. Oral antibiotics may be used to complete therapy if a child is well enough for discharge.

While appendectomy remains the definitive treatment for appendicitis, many patients with perforated appendicitis are now treated with intravenous antibiotics alone with drainage of the abscess if needed. Additionally, some advocate nonoperative treatment with antibiotics only for early appendicitis, especially when the diagnosis is vague.

A study by Kronman et al compared the effectiveness of extended-spectrum versus narrower-spectrum antibiotics for children with appendicitis. The study found that extended-spectrum antibiotics seem to offer no advantage over narrower-spectrum agents for children with surgically managed acute uncomplicated or complicated appendicitis.
[18]

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Appendectomy

The definitive treatment for appendicitis is appendectomy. Historically, appendectomy had a 10-20% false-positive rate, but the widespread use of imaging studies has reduced this rate.

Patients with perforated appendicitis can be divided into 2 cohorts; those whose perforation is discovered in the operating room during appendectomy and those with preoperative evidence of perforation, most commonly seen on CT scans or ultrasounds. Increasingly, the approach in the latter group is conservative (nonoperative) management, with percutaneous drainage if possible and surgery after 8-12 weeks (ie, interval appendectomy).

Patients discovered to have perforated appendicitis during appendectomy should be treated in the same fashion as those with nonperforated appendicitis. The surgeon should complete the appendectomy in a normal fashion.

If a laparoscopic appendectomy is being performed, perforation alone is not a reason for conversion to open appendectomy. However, if an abscess is encountered and drained, placement of a drain in the abscess cavity should be considered. In addition, when an open appendectomy is being performed on a patient with a perforated appendix, the high incidence of wound infection should be considered in terms of skin closure.

In rare instances, the inflammation can be so severe that the appendix cannot be safely identified and removed. To avoid unnecessary morbidity, drainage procedures with subsequent interval appendectomy (see conservative [nonoperative] management) is acceptable.

Conservative (Nonoperative) Management

Historically, a patient with appendicitis, especially perforated appendicitis, was rushed to the operating room for appendectomy; however, this is no longer the case. Conservative management with interval appendectomy may be appropriate for perforated appendicitis. Whyte et al have suggested that interval appendectomy may be safely performed as an outpatient procedure.
[19]

Conservative management begins with a trial of medical therapy. A patient found to have perforated appendicitis based on imaging study findings should be admitted to the hospital, should be placed on a nothing-by-mouth (NPO) diet, and should be given intravenous (IV) fluid resuscitation.

If the patient is hemodynamically unstable or if urine output cannot be measured, a Foley catheter should be placed. IV antibiotics should be started. Generally, antibiotics for this condition are targeted at enteric flora (eg, second-generation cephalosporin, gentamicin, metronidazole; see Medication). If the patient has an abscess that is accessible, percutaneous drainage is performed. Discharge from the hospital is based on lack of fever, tolerance of pain on oral medications, and adequate oral intake.

A patient who does not improve after admission and intravenous antibiotic therapy should undergo surgery for drainage of the infection and appendectomy, if technically feasible. Factors that suggest failure of conservative management include bandemia on admission CBC count, fever of more than 38.3° C after 24 hours of medical therapy, and multisector involvement on CT scan. Medical therapy is deemed to have failed at a median of 3 days. Medical therapy fails in as many as 38% of children with perforated appendicitis.

In children who recover with medical therapy, an alternative to interval appendectomy is to postpone surgery indefinitely. Most patients do well with this approach. Appendicitis recurrence rates range from 0-20%, with a pooled rate of 8.9% found by one large meta-analysis.
[20]

A much higher recurrence rate (72%) is seen in pediatric patients with an appendicolith present during the initial acute episode. Consequently, many experts suggest that interval appendectomy may be needed only in patients with appendicolith.

Most patients who experience recurrence do so within the first 6 months after their initial episode of appendicitis; the longest follow-up to date is 13 years. However, it is not known whether pediatric patients who receive conservative treatment for appendicitis are at risk for recurrence during adulthood. Because of this uncertainty, many pediatric surgeons prefer to perform interval appendectomy.

Delaying definitive surgery is associated with significant resource use, including increased imaging, drainage procedures, and additional admissions. In addition, conservative management with laparoscopic appendectomy performed at a later date poses the risk of misdiagnosis. The major differential diagnoses for acute appendiceal abscess or mass include Crohn disease and malignancy.

The increased use of CT scanning or ultrasonography in the emergent setting has decreased this risk of misdiagnosis. These studies help to confirm the diagnosis of appendiceal mass and also guide drainage interventions. The increased use of technology, combined with improvements in antibiotics, makes conservative management a more attractive and less risky choice in terms of misdiagnosis or treatment failure.

Nonoperative management with antibiotics for early appendicitis is a new concept in the pediatric population and further studies are required prior to routine recommendation of this practice.

A study by Minneci et al looked to determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children. The study enrolled 102 patients, 65 patients/ families chose appendectomy and 37 patients/families chose nonoperative management. The success rate of nonoperative management was 89.2% at 30 days and 75.7% at 1 year. The incidence of complicated appendicitis was 2.7% in the nonoperative group and 12.3% in the surgery. After 1 year, children managed nonoperatively compared with the surgery group had fewer disability days and lower appendicitis-related health care costs.
[21]

A study by Bachur et al reported that of the 4,190 out of 99,001 pediatric appendicitis patients managed nonoperatively, nonoperative management patients were more likely during the 12-month follow-up period to have advanced imaging (+8.9% [95% confidence interval (CI) 7.6% to 10.3%]), ED visits (+11.2% [95% CI 9.3% to 13.2%]), and hospitalizations (+43.7% [95% CI 41.7% to 45.8%]). The study also found that 46% of the patients managed nonoperatively had a subsequent appendectomy.
[22]

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Percutaneous Drainage

Often, patients with gangrenous or perforated appendicitis develop intra-abdominal abscesses.
[23] These may be present at the time of presentation or may develop after surgery or during hospitalization if an interval appendectomy is planned. Commonly, a patient who has a prolonged ileus or fever for more than 5 days postoperatively has an intra-abdominal abscess.

The usual approach is to perform a CT scan of the abdomen and pelvis with oral and intravenous contrast to define the presence of an abscess. If this study confirms the presence and accessibility of an abscess, percutaneous drainage should be performed.

A drain is commonly left in the abscess cavity, and continued drainage is monitored. Once drainage decreases, the drain can be removed. Repeat imaging is not always needed.

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Postoperative Pain Management

Patients who have undergone an appendectomy should be prescribed pain medication upon discharge. Liquid acetaminophen usually suffices in smaller children, with liquid acetaminophen plus codeine or hydrocodone administered for breakthrough pain. The same medication combination in a tablet form can be used in older patients, assuming they are able to swallow the tablets.

Patients who received inpatient narcotics or who are discharged on outpatient narcotics should be cautioned about the possibility of becoming constipated. These patients may need prescribed stool softeners.

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Diet and Bowel Function

Patients with nonperforated appendicitis may be started on clear fluids postoperatively. Diet is advanced as tolerated.

Patients who can tolerate regular diet may be discharged home. These patients have minimal delay in the return of bowel function and do not need to have a bowel movement prior to discharge.

Patients with perforated appendicitis who have immediate appendectomy should remain NPO until their bowel function returns. They should then be started on clear fluids, and the diet advanced as tolerated. Total parental nutrition may be needed in children with prolonged hospitalization from a ruptured appendicitis.

Ultrasonographic examination of the right lower quadrant reveals a greater than 6-mm noncompressible tubular structure shown in cross section. Discomfort was noted as the probe was depressed over this structure. A small amount of free fluid is also noted surrounding the appendix.

Ultrasonographic examination of the right lower quadrant reveals a greater than 6-mm noncompressible tubular structure shown in cross section. Discomfort was noted as the probe was depressed over this structure. A small amount of free fluid is also noted surrounding the appendix.

CT scan depicting a distended tubular structure descending into the pelvis and containing a round calcification (ie, an appendicolith).

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching. for: Abbott Nutritional, Abbvie, speakers' bureau.

Philip Glick, MD, MBA Professor, Departments of Surgery, Pediatrics, and Gynecology and Obstetrics, Vice-Chairperson for Finance and Development, Department of Surgery, State University of New York at Buffalo